Healthcare Provider Details

I. General information

NPI: 1144429564
Provider Name (Legal Business Name): PHILIP CHARLES BOULANGER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9401 FERNLEIGH DR
RICHMOND VA
23235-1311
US

IV. Provider business mailing address

9401 FERNLEIGH DR
RICHMOND VA
23235-1311
US

V. Phone/Fax

Practice location:
  • Phone: 804-389-2606
  • Fax: 804-747-0643
Mailing address:
  • Phone: 804-389-2606
  • Fax: 804-747-0643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: PHILIP CHARLES BOULANGER
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 804-389-2606